Comparison of fibrin glue, bioresorbable tubing and sutures in peripheral nerve repair.

Regeneration of severed rat tibial nerves was functionally and morphologically compared with repair following the use of 3 anastomosis techniques: collagen guide tubes, fibrin glue and conventional microsurgical sutures. In addition, one tibial nerve was crushed in some rats. At ten weekly intervals, functional recovery, assessed by sciatic nerve stimulated evoked contraction of the flexor digitorum muscle, was quicker and more complete following nerve crush than following the anastomosis techniques which were not different from each other. Ten weeks following the surgery, the retrograde transport morphological technique indicated that the anastomosis techniques were not different from each other. The number of labeled tibial motoneurons (tube and suture groups) was significantly less than the crush group, but the glue group was intermediate. Thus, although having less extensive recovery following crush, the quicker and easier techniques of nerve repair, i.e., collagen tubes or fibrin glue, produced comparable anatomical and functional recovery as the more time-consuming, technically demanding microsurgical repair with fine sutures.

Rerouting peripheral nerves for spinal cord lesions.

To provide control of paralyzed limb muscles following spinal cord lesions, peripheral nerves containing motor axons from motoneurons located above a spinal cord lesion could potentially be rerouted to nerves containing motor axons located below the spinal cord lesion. To test this hypothesis in rats, the distal end of a cut tibial nerve, innervated by the L4-6 spinal level, was anastomosed or rerouted to the central end of the cut femoral nerve, innervated by the L3-4 spinal level. Appropriate controls were used. Recovery of lower hind limb motor function was followed at regular intervals, measuring the twitch tension of toe flexion (innervated by the tibial nerve) induced by transcutaneous stimulation of nerve rootlets exiting the spinal cord. After 4-6 months, 54% of motor function returned in the experimental group. Retrograde transport of horseradish peroxidase from the gastrocnemius muscles to spinal motoneuron cell bodies confirmed that the innervation of this group was at a higher level. Furthermore, after an L4 spinal transection, twitch tension responses to spinal cord outlet stimulation remained only in the experimental group. Therefore, a peripheral nerve containing motor axons from above the lesion was rerouted to a distal peripheral nerve to control muscles that would have otherwise been denervated.

Avoiding complications of surgery for nerve compression syndromes.

This article discusses ways in which the operating surgeon can avoid complications in surgery for thoracic outlet syndrome, cubital tunnel syndrome, and carpal tunnel syndrome. Postoperative problems also are discussed.

Complications of the treatment of cubital tunnel syndrome.

Cubital tunnel syndrome is the most common entrapment of the ulnar nerve. Complications in the treatment of cubital tunnel syndrome may be caused by errors in diagnosis, errors in conservative management, and errors of surgical treatment. This article discusses each cause of complications separately, with a division in errors of surgical treatment into complications from decompression of the ulnar nerve, medial epicondylectomy, anterior transposition of the ulnar nerve, intramuscular transposition of the ulnar nerve, subcutaneous transposition of the ulnar nerve, submuscular transposition of the ulnar nerve, and failed surgical treatment.

Role of neuropeptides in pathogenesis of reflex sympathetic dystrophy.

In 1993, a study was undertaken at the Hand Clinics of Loyola University Medical Center in Chicago to investigate the role of the neuropeptides in the pathogenesis of Reflex Sympathetic Dystrophy. All of the patients had recurrent or continuous pain, swelling, and stiffness of one or both extremities following either acute trauma or surgical intervention. All of the patients showed a markedly increased level of bradykinin as well as calcitonin gene-related peptide. The levels of bradykinin were four times as high as the controls. A few showed increased levels of the other neuropeptides. With these results, we agree with Veldman, Goris and others who consider Reflex Sympathetic Dystrophy to be an exaggerated regional inflammatory disorder.

Carpal tunnel syndrome as the initial manifestation of scleroderma.

Two cases of scleroderma (systemic sclerosis) in which carpal tunnel syndrome was the initial manifestation are described. The development of persistent bilateral swelling of the hand after division of the transverse carpal ligament was a clue to the underlying disorder.

Ulnar neuropathy at the elbow: results of medial epicondylectomy.

Retrospective analysis of 48 medial epicondylectomy procedures in 46 patients demonstrated that symptomatic and objective improvement was usual. Most patients experienced improvement of symptoms (98%) and moving two-point discrimination (87%), and many demonstrated improved motor strength (54%). By use of the McGowan scheme for grading ulnar neuropathy, 92% of the patients with grade I neuropathy had a return to normal function. Subdividing patients with grade II neuropathy into grade IIA and IIB on the basis of the extent of motor compromise was useful in predicting postoperative outcome. Forty-five percent of the patients with grade IIA neuropathy had a return to normal ulnar nerve function and only 11% (one patient) in the IIB group had a full recovery. In the group with grade III neuropathy, one patient had improvement to grade II level and the other five remained grade III. No patient in this study demonstrated deterioration of his McGown grade. Medial epicondylectomy is a safe and predictable procedure for the treatment of symptomatic cubital tunnel syndrome.

Benign soft tissue chondromatous lesion of the hand.

Four patients with benign soft tissue chondromatous lesions of the hand have been operated on and were followed for 4 years. During this follow-up period, two patients have had recurrences that were excised, and a third patient with a recurrence is scheduled for operation.

Traumatic longitudinal disruption of the carpus.

Traumatic longitudinal disruption of the carpus is a rare injury that usually occurs through a weak point between the third and fourth metacarpals and the capitate and hamate. Three cases are reported; all injuries were work related and occurred with a broad crushing injury to the hand and wrist. Two patients were treated by fasciotomies, a carpal tunnel release, and excision of a fractured hook of the hamate. The third patient was treated with carpal tunnel release and percutaneous pinning of a wide diastasis. Despite the return of wrist motion, pinch and grip strength remained below normal range in all three patients at follow-up examinations.

Evaluation of impairment of the upper extremity.

Evaluation of impairment of the upper extremity is the product of a team effort by the physician, occupational therapist, physical therapist, and rehabilitation counselor. A careful recording of the anatomic impairment should be made because this is critical in determining the subsequent functional activities of the extremity. The measurement criteria for clinical and functional evaluation includes condition assessment instruments. Some assess the neurovascular system, others assess movements including the monitoring of articular motion and musculotendinous function. Sensibility assessment instruments measure sympathetic response and detect single joint stimulus, discrimination, quantification, and recognition abilities. A detailed description of each assessment is recorded and physical capacity evaluation is only one component of the entire vocational evaluation. This evaluation answers questions regarding the injured worker's ability to return to his previous job. The work simulator is a useful instrument that allows rehabilitation and testing of the injured upper extremity. Job site evaluation includes assessment criteria for work performance, work behavior, and work environment.

Acquired rotational digital deformity in children as a result of finger sucking.

Although most attention to the harmful effects of finger sucking by infants has been on the potential dental deformities, finger deformities also occur. The three cases presented in this article describe radial rotation of the index finger as a result of persistent finger sucking. In the majority of cases rotational deformities spontaneously resolve once finger sucking ceases. In a few cases, particularly when the habit is unduly prolonged, deformities may persist and cause functional impairment. In these patients surgical intervention is indicated. In our cases the rotational digital deformities were treated successfully by rotational osteotomy of either the metacarpal or the proximal phalanx.